General Surgery Coding Alert

Question: The surgeon meets with a patient and recommends a breast biopsy, which the patient schedules for the following week. We report a consult for this visit. On the day of the biopsy, the surgeon re-examines the patient, answers questions, etc. The time spent prior to starting the procedure is 10 minutes. Should we bill this service as 99212-25 on the same day as procedure 19103?


Colorado Subscriber
Answer: In this case, you won't report a separate E/M (even a low-level visit such as 99212, Office or other outpatient visit for the evaluation and management of an established patient ...) with the biopsy (19103, Biopsy of breast; percutaneous, automated vacuum-assisted or rotating biopsy device, using imaging guidance).

Remember: All procedures include an -inherent- E/M component, according to CPT and CMS guidelines. To qualify as a separately billable service, any E/M the physician provides must be both significant and separately identifiable from the E/M component already included in the primary procedure.

If the surgeon had provided the initial E/M service and the biopsy on the same day, you could report the E/M service separately using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). In this case, however, the surgeon has already conducted a full E/M workup prior to the biopsy, and you have already coded for this service.

At the time of the biopsy, if the patient has no new complaint or substantial change in her condition that prompts a new history, exam and medical decision-making process, you should not report a second E/M service. Report the biopsy only for this visit.